A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their access to certain pharmacies. The report, seen by the Wall Street Journal, comes after a 32-month investigation and precedes a hearing involving executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a CVS Health company)—handle around 80% of prescriptions in the United States.
The committee discovered that these PBMs have established preferred drug lists that prioritize higher-priced brand-name drugs over cheaper alternatives. One instance highlighted in the report includes emails from Cigna that discouraged the use of more affordable alternatives to Humira, a medication for arthritis and autoimmune diseases that was priced at $90,000 annually, despite the availability of a similar drug at half that cost.
Additionally, the report indicated that Express Scripts informed patients they would face higher costs at local pharmacies compared to obtaining a three-month supply through their mail-order service, effectively restricting patient choices regarding where to fill prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that the increasing consolidation among PBMs has led to the top six managing nearly 95% of all U.S. prescriptions. The FTC expressed concern regarding the significant control these PBMs have over patients’ access to affordable medications, highlighting potential conflicts of interest as vertically integrated PBMs may favor their own affiliates over independent pharmacies.
FTC Chair Lina M. Khan emphasized that these findings suggest PBMs are inflating costs for cancer medications, resulting in over $1 billion in additional revenue for them.